flap techniques

1. PERIODONTAL SURGERY
Periodontal flaps
Ass. Prof. Enas Elgendy

2. Lecture outlines
• Definition
• Indication of flap surgery
• Classification of flaps
• Advantages of the periodontal flap
• Types of Incisions
• Flap techniques for pocket therapy:
1. Modified Widman flap
2. Un displaced flap (excisional procedure of the gingiva)
3. Apically-displaced flap
4. Distal molar surgery (Distal Wedge)
5. Excisional new attachment procedure ENAP

3. Periodontal flap
• Incising the gingival tissues with the purpose of controlling or
eliminating the periodontal diseases.
• Gingiva &/or oral mucosa is surgically elevated from underlying tissue
for accessibility &visibility of bone &root.

4. Periodontal surgery may be
Resective Procedures.
It is the procedure that means
to eliminate or reduce the
pocket, by excising or
amputating the tissue
constricting the pocket wall.
e.g;
Gingivectomy,
Gingivoplasty,
Apically positioned flap
with or without osseous
surgery.
New attachment
procedures.
It is the reunion of
connective tissue by
formation of new cementum
with inserting collagen fibers
on root surface that has been
deprived of its periodontal
ligament e.g;
Closed curettage.
Excisional new attachment
procedure (ENAP).
Open flap curettage.
Modified widman flap
procedure.
Regeneration procedures.
The use of regenerative
materials, including bone
grafts, barrier membranes,
and wound-healing agents,
are well documented.
Intrabony defects,
particularly vertical defects
with multiple osseous
walls, are often amenable
to regeneration with these
techniques.
Papilla preservation flap
Conventional flap with
regenerative procedures

5. -Gingivectomy →resect soft tissue wall of pocket
-Flap surgery →displace soft tissue wall of pocket

6. Indication of Flap Surgery
•Gain access for root debridement
•Pocket elimination or reduction → patient can
maintain root surface free of plaque
•Reshaping of soft &hard tissues
•Regeneration of alveolar bone, PL & cementum

7. Periodontal flaps can be classified based on the following:
• Bone exposure after flap reflection
• According to Position or Placement of the flap after
surgery
• According to Design of Flap/management of the
papilla
Classification of flaps

8. A) According to bone exposure during reflection (thickness of the flap):
1.Full thickness flaps
2. Partial “split” thickness flap

9. Based on bone exposure after flap reflection
Partial-thickness (mucosal) flaps (split-thickness flap)Full-thickness (mucoperiosteal) flaps
The flap includes only the epithelium and a layer of
the underlying connective tissue. The bone remains
covered by a layer of connective tissue, including the
periosteum.
All soft tissue, including the periosteum, is reflected to
expose the underlying bone.
Sharp dissection is necessary to reflect a partial split
thickness flap. Technique is relatively difficult
A periosteal elevator is used to separate the
mucoperiosteum from the bone.
It is indicated:
the flap is to be positioned apically, coronal or
laterally.
When periosteum is left on bone:
 Prevent marginal bone loss
 used for suturing the flap to keep in position
(apically displaced)
It is indicated:
osseous surgery is needed (including regenerative
techniques).

10. Displaced flapsUndisplaced flaps (repositioned)
When the flap is positioned
reflection should extend to the level of alveolar
mucosa
When the flap is returned and sutured to its original
position
Coronally: coronally positioned flap usually for
anterior teeth
Laterally: laterally positioned flap (pedicle flap)
in mucogingival surgery
Apically: apically positioned flap.
N.B. Palatal flaps cannot be displaced because of
the absence of unattached gingiva.
Based on According to position or placement of the flap after surgery

12. In order to displace the flap in any direction, reflection should
extend to the level of alveolar mucosa. Moreover vertical
incisions are performed at both ends of the flap. Palatal flaps
cannot be displaced owing to the absence of alveolar mucosa.

14. The interdental papilla
Facial papilla Lingual papilla Col region
The interdental papilla occupies the space in the interdental embrasure apical to the
contact point. There are three parts of interdental papilla:

15. The interdental papilla
• Interdental papilla (IDP) acts as a biological barrier which protects the
underlying periodontal structures, apart from playing an important role in
esthetics.
• The loss of IDP as a result of periodontal disease or of periodontal therapy
leads to esthetic (black triangle), phonetic, and food impaction problems.
This is why, it is important in periodontal surgery to preserve the inter dental papilla.

16. Papilla preservation flapSplit papilla flaps (Conventional flaps)
The entire interdental papilla is
incorporated in either the facial or lingual
flap.
The interdental papilla is split beneath the
contact point into facial papilla which is
included in the facial flap and lingual papilla
which is included in the lingual flap.
Papilla preservation flaps
1. When the interdental spaces are too
wide
2. When the flap is to be undisplaced.
Conventional flaps
1. When the interdental spaces are too
narrow
2. When the flap is to be displaced.
According to Design of Flap/Based on Management of the papilla

18. Advantages of the Periodontal Flap
• Existing gingiva is preserved.
• Marginal alveolar bone is exposed so as to
identify the morphology of the bony defect (1
wall, 2 wall or 3 wall intra bony defect) and so to
make proper treatment.
• Furcation areas are exposed and so the degree of
involvement can be detected.
• Flap can be repositioned at its original level or
shifted apically or coronally, thereby making it
possible to adjust the gingival margin.
• Regenerative techniques cannot be performed
without reflecting a flap such as placing grafts or
treatment by guided tissue regeneration (GTR).
• Flap procedure preserves the oral epithelium and
may make the use of surgical dressing not so
important as compared to gingivectomy.
• Post operative period is usually more pleasant for
the patient when compared to gingivectomy.

19. Incisions for Conventional Flap
1. Horizontal incision
a) Internal (reverse) bevel incision
b) Crevicular (second, intrasulcular/sulcular) incision
c) The third or interdental incision

20. Incisions for Conventional Flap
2. Vertical incision
Oblique releasing incision
Diagram of the vertical incision: the broken lines
illustrate the incorrect incision where the flap
base is smaller than the flap margin. If vertical
incisions are renounced, tearing may occur at
the end of the horizontal incision during flap
mobilization (small picture).
Facial vertical incisions should not be made in the
center of an interdental papilla or over the radicular surface
of a tooth.

22. Incision For Papilla preservation flap
• Crevicular with no Interdental incision
Bard-Parker scalpel blades and handle

23. • Increase accessibility to root deposits for scaling and root
planing.
• Eliminate or reduce pocket depth via resection of the pocket
wall.
• Gain access for osseous respective surgery.
• Expose the area to perform regenerative methods.
When should one consider for surgical pocket
therapy?

24. Flap Surgery for pocket therapy
1- Modified Widman flap.
2- The undisplaced (unrepositioned) flap
3-Apically displaced flap.
4- Distal Wedge procedure
5- Excisional new attachment procedure ENAP

25. Modified Widman flap
Technique
• Primary incision: An inverse bevel incision directed at
the alveolar crest is made 0.5-1mm from the gingival
margin and parallel to the long axis of the tooth.
• It is important to produce enough scalloping of the
interdental incision in order obtain primary closure
interdentally. Sometimes a crevicular incision may be
used when esthetics is of concern or minimal gingival
width is present.

26. Modified Widman flap
Flap elevation: Elevation of a full thickness flap is done using a periosteal
elevator exposing 1-2 mm of alveolar bone. Vertical releasing incisions are
not usually needed.

27. Modified Widman flap
• Second incision: This incision is made from the bottom of the pocket
to the alveolar crest around the neck of each tooth.

28. Modified Widman flap
• Third incision: After the flap is reflected, a third incision is made in
the interdental spaces using an interproximal knife and the gingival
collar is removed.

29. Modified Widman flap
• Tissue tags and granulation tissue are removed using a curette.
• Root surfaces are checked and scaled and root planed. Residual
periodontal fibers attached to the tooth surface should not be
disturbed.

30. Modified Widman flap
• Suturing: flaps are then replaced at their original position and secured by
tight interrupted sutures . Effort must be made to keep the facial and
lingual interproximal tissues as close to each other as possible so that no
interproximal bone remains exposed at the time of suturing.

31. Modified Widman flap

32. Modified Widman Flap (MWF)

33. Modified Widman flap
INDICATIONS:
Access and visualization of the root surface.
Effective with pocket depths of 5-7 mm
When regeneration is the goal and not total pocket irradiation.
CONTRAINDICATIONS:
Lack of or very thin and narrow attached gingiva can render the
technique difficult, because a narrow band of attached gingiva does
not permit the initial scalloped incision (internal gingivectomy).

34. Modified Widman flap
Advantages
• Adaptation of healthy connective tissues to the root surfaces.
• Better esthetics when compared to apically positioned flap.
• Less potential for root hypersensitivity as compared to apically positioned flap.
• Preservation of interdental tissues allows for proper coverage of intrabony defects as
well are grafts placed in bony defects.
Disadvantages
• May lead to residual probing depth in the presence of infra bony pockets.
• New attachment is unpredictable.
• Healing is usually by a long junctional epithelium.
It does not attempt to reduce the pocket depth (except for reduction that occurs
during healing as a result of tissue shrinkage), but it does eliminate the pocket lining.

35. Post operative care
Patients should follow these instructions:
• Avoid eating or drinking for 1 hour.
• Not to rinse vigorously with hot water.
• Avoid eating hard, sharp or sticky food
• Patient may take an analgesic if there is pain when the anaesthetic
wears off.
• Chlorhexidine gluconate 0.2% may be used twice daily for plaque
control on the operated side with the dressing until proper
mechanical plaque control is resumed.
• If there is bleeding, patient is told to exert pressure on the dressing
for 15 minutes using a piece of gauze. Patient should use the tooth
brush on unoperated side.

36. • Post-operative antibiotics should not be routinely prescribed.
Antibiotics may be prescribed for a diabetic patients or medically
compromised patients or in case of regenerative techniques.
• Dressing is usually removed after 1 week.
• All debris must be completely removed and the wound washed with
warm saline. If wound is not sufficiently epithelialized or if it is tender,
a new dressing is applied for a further week. Patient is instructed to
start gentle tooth brushing with a soft tooth brush.
• Patient’s oral hygiene must be followed up until healing is complete
followed by a 3-6 month follow up.
• These post-operative instructions are applicable for all periodontal
surgical techniques.
Post operative care

37. Modified Widman flap
• If a modified Widman flap is performed in an area with a deep intrabony
lesion, bone repair may occur within the defect at its most apical portion.
Crestal bone resorption is also seen as a response to the flap procedure
and crestal bone exposure.
• Amount of bone fill depends on: the anatomy of osseous defect (e.g,
three wall intrabony defect often provides a better prognosis for bone
repair than two or one-walled defects and the amount of crestal bone
resorption.

38. Healing of modified Widman flap
• Healing of MWF will begin by organization of the blood clot between
the tooth and flap into granulation tissue.
• This granulation tissue is slowly replaced by connective tissue over
the next 2-5 weeks.
• Epithelium proliferates over the connective tissue wound almost to its
pre-operative position. If the root is free of irritants, the long
junctional epithelium can adhere to it. A mature long junctional
epithelial attachment may take several weeks to form.
Give reason
Why it is not allowed to measure probing
pocket depth before 3 months After
MWF?

39. • The modified Widman flap results in
healing by a long junctional epithelium
with some bone fill with or without a
true connective tissue attachment.

40. Repair and Regeneration

41. Healing of
modified
Widman flap:

42. Apically positioned flap
This technique is indicated for:
• Pocket eradication.
• Preserving or increasing the zone of attached gingiva.
• It is also considered one of the mucgogingival techniques. This flap could
be a full thickness (mucoperiosteal) or split thickness (mucosal) flap
depending on the purpose.

46. Apically positioned flap
• Healing:
• The inner surface of the flap in contact with the bone undergoes
inflammation, organization and healing. The thin blood clot is replaced by
granulation tissue in about a week. This matures into collagenous
connective tissue in 2-5 weeks. The inner surface of the flap unites with the
bone to produce a mucoperiosteum which will increase the attached
gingival zone.
• Epithelium will begin to proliferate 2 days after surgery from the flap
margin over the connective tissue wound. The epithelium will migrate
apically at a rate of 0.5 mm per day to form a new junctional epithelium. A
mature epithelial attachment takes about 4 weeks to form. Some
resorption of the alveolar bone margin will occur as a result of raising the
flap which is about 0.5 mm. Connective tissue attachment will reform
between the marginal tissue and root cementum from the bone margin to
the base of the junctional epithelium. This will prevent further apical
migration of the junctional epithelium.

47. • Advantages
It may give more stable results since pockets are totally
eliminated and the dentogingival junction is normal as
compared to the long junctional epithelium which
results after the MWF.
• Limitation
It cannot be done on the palatal aspect and it leads to
increased clinical crown lengthening.

48. Undisplaced (unrepositioned) flap
The undisplaced flap is the most commonly performed type of
periodontal surgery. It differs from the modified Widman flap in that the
soft tissue pocket wall is removed with the initial incision thus it consider
internal bevel gingivectomy.
.

49. •The pockets are measured with the periodontal probe, and a bleeding marks were
made.
•The initial, internal bevel incision is made after the scalloping of the bleeding
marks on the gingiva. The incision is usually carried to
, . The thicker the tissue, the more
apical is the ending point of the incision
•The second or crevicular incision
• The flap is reflected with a periosteal elevator (blunt dissection). Usually there is
no need for vertical incisions because the flap is not displaced apically.
• The interdental incision is made with an interdental knife.
• The triangular wedge of tissue created by the three incisions is removed with a
curette.
•The area is debrided

54. Distal Wedge Excision
• Indication
• Pocket elimination in edentulous areas.
• Treatment of distal pockets on the maxillary or mandibular arches.
• Crown lengthening: to re-contour periodontal tissue that form on the abutment tooth adjacent to
edentulous area, maxillary tuberosity
• Better if sufficient attached gingiva distal to tooth is present (simpler & no risk of recurrence).
• Pocket depth of about 6-7 m (Better) &if distal furcation is slightly involved,
• Limitation
• Free movable gingiva(recurrence)
• Lingual nerve

55. Distal Wedge Excision
Techniques:
1. Half moon shaped inverse bevel incision from mid buccal to mid
palatal aspect.- Corresponding intrasulcular incision.
2. Parallel incisions 10 mm distal to tooth.
3. Distal perpendicular incisions
4. Undermined incisions for flap creation( hatched area)
5. Contouring gingivectomy to eliminate redundant tissue.

56. Distal Wedge Excision
Suturing and gingivectomy
of redundant distal gingival
tissues
Flap reflection – Root planning
Wedge removal

58. Excisional new attachment procedure ENAP
It is subgingival curettage performed with a knife to remove the gingival epithelium.
-Gain new attachment
Decrease probing depth
-Access root surface
-Maintenance of esthetics

59. Excisional new attachment procedure ENAP
Technique:
• After adequate anesthesia ENAP consists of an internal
bevel incision performed with a surgical knife (Bard-Parker
blade no. 11 or 15. Carry the incision interproximally on
both the facial and the lingual side, attempting to retain as
much interproximal tissue as possible. The intention is to
cut the inner portion of the soft tissue wall of the pocket,
all around the tooth.
• Remove the excised tissue with a curette, and carefully
perform root planing on all exposed cementum to achieve
a smooth, hard consistency. Preserve all connective tissue
fibers that remain attached to the root surface.
• Approximate the wound edges; if they do not meet
passively, recontour the bone until good adaptation of the
wound edges is achieved. Place sutures and a periodontal
dressing.